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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DALCARATION I hcrcby allirm undcr pcnolry of pcrjury that I am cxcmpl Frcm thc Coilraclors' LiccnE law for thc following reasn (Ss.7031.5 Busincss ard Profcssion Codc): Any CiIy or County which rcquircs a Frmil to conslruct, allcr. improvc, &mlish or rcpair any slructure. prior to its issuancc, also rcquircs lhc applicant for such pcmit to filc a sigrcd slatemnl thal hc or she is liccnsd pu.Grnt to lhc Fovisions of thc Contmctor's Liccnscd [aw (Chaplq 9. Comcrcing wilh Setion 70O0 of Division 3 of the Busircss and Professions Codc) or that hc or shc is cxcmpt thcrcfrom aM thc basis for thc allcgcd cxcrnption. Any violalion of Sdicn 7031.5 by any applicant for a pcmit subjets thc applicant to a civil pcnalty of not mrc than fivc hundrcd dollars (S50O). _1. as owner of thc propcrty. or my cmployccs with wagcs as lhcir sole compcnsation. will do thc work and thc stnrcturc ls not intendcd or offcrcd for sale (Scrc.7044, Busincss and Profcssions Codc: Thc Contraclor's Liccnsc Law does not apply to an owncr of thc proJrcrty who builds or improvcs thcrcon. and who does such work hirnsclf or hcrself or through his or hcr own employecs, providcd that such improvcrncnts arc not intcndcd or offcrcd fbr sale. If, howevcr. thc building or improvcnrcnt is sold within onc ycar of cornplction. thc Owner Buildcr will have thc burden of proving that he or shc did not build or improvc thc property for the purposc of salc). _1. as owner of the propcrty, am cxclusively contracting with liccnscd contractors to construct thc projcct (Sec. 7W, Busincss and Profcssbn Code: Thc Contractor's Licensc Law docs not apply to an owncr of proJrcrty who builds or improves thereon, and who contracts for such projects with a Contractor(s) Iiccnsed pursuant to thc Contraclor's Liccnsc hw). -lantexemptundcrSection-.B.&P.C.forthisreason' WORKF'RS' COMPENSATION DECLARATION I hcrcby affium under penalty of pcrjury one of the following declarations: _l have and will maintain a Certificate of Consent to Sclf-lnsurc for workers' comgrcnsation. as providcd for by Section 3700 of the Labor Code. for the pcrformance of thc work for which the permit is issued./ lu(have and will maintain workers' compcnsalion insurance, as required by Scction 3700 of thc Lubor Code, for the pcrformance of thc work for which this perrnit is issucd. My workers' comlrcnsation insurance carricr and policy numbcr are: c*ri"r'^llatncl poricyNu^*r, BNULI/Cot53'76o Expires:o+/o?/ LL _l ccrtify that in the prforrrurncc of thc work for which this pcrmit is issued. I shall not cmploy any lrcrson in any manncr so as to bccomc subjcct to the workcrs'cornpcnsation laws of California, and agrcc that if I should beconrc subject to the workers' compcnsation provisions of Scction 3700 of thc l-abor Code. I shall. forthwilh comply with thosc provisions. WARNING: Failure lo sccurc workcrs' compcnsation coverage is unlawful, and shall subjcct an employcr to criminal grenaltics and civil tines up to one hundrcd thousand dollars ($l00.m0), in addition to thc cost of compcnsation. damages as provided for thc Section 3076 of the [abor Code. intcrcst and attorncy's fecs. o,rc,â‚¬? o8/13/2( LI C IT NSI'D CONTIT.,\ CTO R DT.'CLAItA'I'I()N I hcrcby alfirnr undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (conrmcncing with Scclion 7000) of Division 3 of thc Busincss and Profcssions Codc. and rny liccnsc is in full force and cfl'ccl. Liccnsc o Numbcr:I oz76 L7 orru,Og/lo/21.CL W I hcrcby affrm undcr pcnalty of JErjury that thcrc is a construction lcnding agcrcy for thc Isforllrrec of thc work for shich this pcrmil is issucd (Sff. 3097, Civ. C.). Lrndcr's Namc: lrnder's Addrcss: APPLICANT DECLARATION I trcrcby aflirm under penalty of pcrjury onc of thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Title 40, Part6) _Requ ircd lrtter of Notificat ion _l ccrtify that thc fedcral rcgulations rcgarding asbcstos removalare not applicablc to this projcct. _l ccnify rhat I havc rcad this application and slalc that lhc abovc infomtion is coret. I lgrc to comply sith 8ll Cilyand County ordinarccs and Statc lrws rclrting to building construction. a[d hcrcby aulhorizc rcprcsntativcs of this City md CoufiFoqts uIDn tlrc atnvc mcntioncd propcrty for Applicant or Agent Permitee name o*",to?/t9/z\ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/Vent/l nsu Iation Roof Sheathinq Shear Wall Framinq Insu Iation/Enerqy Drvwall Ext./lnt. Lath Brown Coat [Vlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif tl FINAL .lfiru|n ?/tqh,, Certificate of Occu Notes, Remarks, Etc.v Dale: Owner:- a